Provider Demographics
NPI:1942334768
Name:WAYNOKA MENTAL HEALTH AUTHORITY
Entity Type:Organization
Organization Name:WAYNOKA MENTAL HEALTH AUTHORITY
Other - Org Name:NORTHWEST SUBSTANCE ABUSE TREATMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN OF THE TRUSTEE BOARD
Authorized Official - Prefix:MR
Authorized Official - First Name:SIDNEY
Authorized Official - Middle Name:DON
Authorized Official - Last Name:SMILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MED IN COUNSELING
Authorized Official - Phone:580-824-0674
Mailing Address - Street 1:PO BOX 135
Mailing Address - Street 2:
Mailing Address - City:WAYNOKA
Mailing Address - State:OK
Mailing Address - Zip Code:73860-0135
Mailing Address - Country:US
Mailing Address - Phone:580-824-0674
Mailing Address - Fax:580-824-0676
Practice Address - Street 1:1095 NICKERSON ST
Practice Address - Street 2:
Practice Address - City:WAYNOKA
Practice Address - State:OK
Practice Address - Zip Code:73860-1252
Practice Address - Country:US
Practice Address - Phone:580-824-0674
Practice Address - Fax:580-824-0676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK76244324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK54197143OtherTPIN NUMBER